Clinical prediction method for precise extubation of old general anesthesia long-term mechanical ventilation patient in PACU

Abstract

The invention discloses a clinical prediction method for PACU precise extubation of an old general anesthesia long-term mechanical ventilation patient, and belongs to the field of clinical medicine statistics, and the method comprises the steps: S1, carrying out the inclusion of the patient according to a preset inclusion standard and an exclusion standard; s2, informing the elderly patients meeting the inclusion standard of agreement; s3, anesthesia resuscitation is conducted on the old general anesthesia patient entering the PACU, and then whether the patient can conduct a spontaneous respiration test or not is judged according to evaluation before off-line and predefined off-line preparation of an SBT test; s4, bedside lung ultrasonic examination is carried out before tube drawing, the trachea cannula is pulled out after the SBT test is passed, nasal catheter oxygen inhalation (3 L / min) is conventionally carried out after tube drawing, the blood oxygen saturation degree is recorded, and blood gas analysis examination is carried out 5 min after tube drawing; s5, predicting the possibility of tube drawing through the column diagram constructed by the method; according to the invention, medical staff can be guided to determine the preparation condition of extubation of old patients after general anesthesia, and long-term negative effects related to extubation failure can be reduced as much as possible.

Description

TECHNICAL FIELD

[0001] The present application relates to a clinical prediction model, in particular to a clinical prediction method for precise extubation of elderly patients with general anesthesia and long-term mechanical ventilation in PACU. BACKGROUND

[0002] The global aging of the population has led to an increase in the number of surgeries in elderly patients. However, with increasing age, there are progressive changes in the main structure and function of the lung, including impaired lung elasticity, impaired defense mechanisms, weakened respiratory muscle strength, and reduced lung responsiveness to anesthesia. Smetana showed that nearly 33% of patients over 65 years old who underwent surgery developed postoperative pulmonary complications. It can be seen that elderly patients are inherently high-risk for pulmonary complications. Common postoperative pulmonary complications include pleural effusion, atelectasis, pneumonia, acute respiratory distress syndrome, cardiogenic pulmonary edema, and the need for long-term mechanical ventilation after surgery. This can lead to prolonged hospital stays, increased financial burden on patients, and increased long-term mortality. Therefore, accurately determining the optimal extubation time for elderly patients after surgery to reduce the occurrence of ventilator-associated pulmonary complications has important clinical and social value.

[0003] Clinical practice guidelines for critically ill patients generally recommend a clear, albeit imperfect, protocolized weaning and extubation program, including weaning preparation assessment, spontaneous breathing trial (SBT) assessment, extubation, and consideration of prophylactic non-invasive ventilation or high-flow oxygen. However, even if SBT is successful, 3%-30% of patients still require reintubation with endotracheal tube due to respiratory distress after extubation. It is particularly important to predict the successful extubation of these patients. The decision to extubate is usually based on the results of SBT and the clinical judgment of the attending physician. So far, there is no simple clinical model that is a strong predictor of extubation failure.

[0004] Lung ultrasound score (LUS) has been shown to accurately predict extubation failure by detecting significant pulmonary edema that occurs during SBT, while diaphragmatic excursion (DE) can be used to quantitatively assess diaphragmatic activity to assess extubation success. However, these studies were conducted in the intensive care unit (ICU), and most patients go to the post-anesthesia care unit (PACU) for the first time after surgery, to our knowledge, there has been no evaluation model for extubation of postoperative patients. Based on the above background, we propose a hypothesis that by comprehensively evaluating multiple physiological parameters, including LUS, DE, and oxygenation index (OI), a new, more accurate clinical prediction model can be constructed in PACU to predict the extubation outcome of elderly surgical patients. This model is expected to provide clinicians with more objective, individualized, and precise extubation criteria, thereby reducing unnecessary mechanical ventilation time, reducing the risk of complications, and ultimately improving perioperative rapid recovery in elderly surgical patients. SUMMARY

[0005] The application aims to provide a clinical prediction method for precise extubation of elderly patients with general anesthesia and long-term mechanical ventilation in PACU, so as to formulate a more precise extubation plan for elderly patients.

[0006] To achieve the above-mentioned purpose, the specific scheme is as follows:

[0007] The clinical prediction method for precise extubation of elderly patients with general anesthesia and long-term mechanical ventilation in PACU comprises the following steps:

[0008] S1: According to the pre-set inclusion criteria and exclusion criteria, the elderly patients are included;

[0009] S2: The elderly patients meeting the inclusion criteria are informed of the informed consent;

[0010] S3: The elderly patients with general anesthesia entering the PACU are subjected to anesthesia recovery, and then the pre-removal evaluation and pre-defined removal preparation according to SBT are performed to determine whether the patient can perform the spontaneous breathing test;

[0011] S4: Bedside lung ultrasound examination is performed, and then SBT test is performed, and after the SBT test passes, the tracheal cannula is removed;

[0012] S5: The possibility of extubation is predicted by the nomogram constructed by the application.

[0013] Further, in step S1, the inclusion criteria of the patient are: age ≥ 65 years old, surgery under general anesthesia, mechanical ventilation for more than 3 hours; the exclusion criteria of the patient are: tracheostomy, unable to perform lung or diaphragm ultrasound examination (morbid obesity, chest dressing), central respiratory failure, myasthenia gravis, diaphragmatic self-activity disappearance, and combined end-stage cardiopulmonary disease.

[0014] Further, in step S2, the steps of lung ultrasound score include:

[0015] 0 points, normal lung ventilation: mainly A line, i.e. normal lung;

[0016] 1 point, moderate reduction of lung ventilation: there are multiple isolated B lines or fused B lines less than 50% of the scanned intercostal space when vertical scanning;

[0017] 2 points, severe reduction of lung ventilation: diffuse fused B lines or very small patchy consolidation under the pleura;

[0018] 3 points, complete disappearance of lung ventilation: liver-like change of lung tissue with or without bronchial inflation sign.

[0019] The LUS score of each region is calculated according to the ultrasound image of the front, lateral and back of the patient's lung, and the scores of 12 regions and the total LUS score are recorded respectively.

[0020] Further, in step S3, the predefined offline preparation is: SpO2≥90% when FiO2≤0.4, positive end-expiratory pressure≤8cmH2O, low / no dose of vasopressor.

[0021] Further, in step S4, after extubation, oxygen is inhaled through a nasal catheter; the gas flow is adjusted to maintain SpO2 greater than or equal to 92%, and if any signs of respiratory distress appear, non-invasive respiratory support is used under the supervision of a responsible physician and assisted ventilation or re-intubation is performed.

[0022] Further, the following indicators change after extubation, assisted ventilation or re-intubation is immediately performed:

[0023] (1) RR>35bpm for more than 5min;

[0024] (2) SpO2<90%;

[0025] (3) HR>140bpm or HR change>20%;

[0026] (4) PaO2<80mmHg when FiO2≥50%;

[0027] (5) PaCO2>45mmHg or PaCO2 change≥20% after extubation, pH<7.33;

[0028] Further, the nomogram contains the type of surgery, the first ALB after surgery, the OI 5min after extubation, the first AST after surgery, the back LUS score, the overall LUS score and the intubation history.

[0029] In summary, the present application has the following beneficial effects relative to the prior art: the model provided by the present application can guide medical personnel to decide the extubation preparation of elderly patients in general anesthesia surgery, and help clinicians to reduce the long-term adverse consequences related to extubation failure as much as possible. BRIEF DESCRIPTION OF DRAWINGS

[0030] The drawings described herein are used to provide further understanding of the present application, and form a part of the present application. The illustrative embodiments of the present application and their descriptions serve to explain the present application, and do not constitute an improper limitation on the present application. In the drawings:

[0031] Figure 1 Flow chart of the clinical prediction model for PACU precise extubation of elderly general anesthesia long-term mechanical ventilation patients provided by the present application;

[0032] Figure 2 Calibration curve for the nomogram prediction;

[0033] Figure 3 Lung ultrasound image;

[0034] Figure 4 is a nomogram.

[0035] Figure 5 is a flow chart of patient inclusion. DETAILED DESCRIPTION

[0036] It should be noted that the embodiments in the present application and the features in the embodiments can be combined with each other without conflict. The present application will be described in detail below with reference to the accompanying drawings and in combination with the embodiments.

[0037] It should be noted that the terms used herein are only for the purpose of describing specific embodiments and are not intended to limit the exemplary embodiments according to the present application. As used herein, the singular form can also include the plural form unless the context clearly indicates otherwise, and it should also be understood that when the terms "comprise" and / or "include" are used in the specification, there is a reference to the presence of a feature, step, operation, device, component, and / or combinations thereof.

[0038] The relative arrangement, numerical expressions, and numerical values of the components and steps set forth in the embodiments are not limiting to the scope of the present application unless specifically stated otherwise. At the same time, it should be understood that the sizes of the various parts shown in the drawings are not drawn in accordance with the actual proportional relationship for the purpose of description. The techniques, methods, and devices known to those of ordinary skill in the relevant art can not be discussed in detail, but in appropriate cases, the techniques, methods, and devices should be considered as part of the authorized specification. In all examples shown and discussed herein, any specific value should be interpreted as merely exemplary and not as a limitation. Therefore, other examples of exemplary embodiments can have different values. It should be noted that similar reference numbers and letters represent similar items in the following drawings, so once an item is defined in one drawing, it does not need to be further discussed in subsequent drawings.

[0039] After a patient under general anesthesia undergoes a surgical operation, the patient is transferred to a post-anesthesia care unit (PACU) with a tracheal tube. The attending physician decides to extubate the patient according to the results of a spontaneous breathing test (SBT) and the clinical symptoms of the patient, and judges the possibility of successful extubation. The traditional extubation method requires a high level of experience for clinicians, and it is difficult to integrate a set of accurate clinical prediction standards.

[0040] To solve this problem, as shown in Figure 1 and Figure 2 The present application provides a clinical prediction method for precise extubation of an elderly patient under general anesthesia and long-term mechanical ventilation in a PACU, comprising the steps of:

[0041] S1: selecting a suitable patient according to pre-set patient inclusion criteria and patient exclusion criteria;

[0042] As a preferred, in step S1, the inclusion criteria of the patient is: age≥65 years, surgery under general anesthesia, mechanical ventilation for more than 3 hours; the exclusion criteria of the patient is: tracheostomy, unable to perform lung or diaphragm ultrasound examination (morbid obesity, chest dressing), central respiratory failure, myasthenia gravis, loss of diaphragmatic autonomic activity, combined with end-stage cardiopulmonary disease.

[0043] S2: According to the lung ultrasound score, the type of operation, the history of intubation and other factors, the extubation risk of the elderly patients meeting the inclusion criteria is informed, so as to realize more effective extubation decision. And bedside lung ultrasound examination is performed on the selected patients.

[0044] As a preferred, as shown in Table 1, in step S2, the step of lung ultrasound score includes: comprehensive scanning of 6 regions of each lung (upper and lower regions of the front, lateral and posterior fields marked by the anterior and posterior axillary lines). Each region defines 4 ultrasound ventilation patterns:

[0045] (1) Normal ventilation: presence of lung sliding with A-line or less than two isolated B-lines;

[0046] (2) Moderate lung ventilation loss: multiple well-defined B-lines (B1 line—score 1);

[0047] (3) Severe lung ventilation loss: multiple confluent B-lines (B2 line—score 3);

[0048] (4) Lung consolidation: liver-like lung tissue with or without bronchial air sign. For a given region of interest, points are assigned according to the worst ultrasound pattern observed.

[0049] Table 1 Lung ultrasound score

[0050]

[0051] As Figure 3 shown, the LUS score is based on dividing the lung into 12 regions, scanning each lung region, scoring each subregion according to the scanning results, and adding the scores of the 12 subregions to obtain the final score. The minimum score is 0 and the maximum score is 36; the higher the score, the more severe the lung lesion. The specific scoring details are as follows:

[0052] 0 points: normal lung gas content (i.e. normal lung);

[0053] 1 point: moderate reduction in lung gas content, presence of multiple isolated B-lines or confluent B-lines less than 50% of the intercostal space on vertical scanning;

[0054] 2 points: severe reduction in lung gas content, diffuse confluent B-lines occupying all intercostal spaces;

[0055] 3 points: complete disappearance of lung aeration, presence of lung consolidation.

[0056] The total, anterior, lateral and dorsal LUS scores range from 0 to 36, 0 to 12, 0 to 12 and 0 to 12, respectively. Lung ultrasound measurements were performed 5 minutes before extubation in patients, three measurements were performed and the mean was calculated.

[0057] S3: Anesthetic recovery is performed on elderly patients under general anesthesia who enter the PACU, then a pre- weaning evaluation and predefined weaning preparation are performed according to the SBT to determine whether the patient can perform a spontaneous breathing test;

[0058] As a preference, in step S3, the predefined weaning preparation is: SpO2≥ 90% with an inhaled oxygen fraction (FiO2) ≤ 0.4, positive end-expiratory pressure ≤ 8 cmH2O, low / no dose of vasopressors. The patient is connected to the ventilator for 30 minutes with low-level pressure assistance (5 positive end-expiratory pressure and 5-7 pressure support level).

[0059] S4: A bedside lung ultrasound is performed, then a SBT test is performed, after which the endotracheal tube is removed; after extubation, oxygen is administered through a nasal catheter. The gas flow is adjusted to maintain SpO2 greater than or equal to 92%. If any signs of respiratory distress appear, non-invasive respiratory support is used under the supervision of a responsible physician and assisted ventilation or re-intubation is performed.

[0060] The evaluation criteria for assisted ventilation / re-intubation include:

[0061] (1) RR > 35 bpm for more than 5 min;

[0062] (2) SpO2 < 90%;

[0063] (3) HR > 140 bpm or HR sustained change > 20%;

[0064] (4) PaO2 < 80 mmHg with FiO2 ≥ 50%;

[0065] (5) PaCO2 > 45 mmHg or change in PaCO2 ≥ 20% after extubation, pH < 7.33;

[0066] (6) Symptoms of respiratory muscle fatigue or increased respiratory difficulty.

[0067] S5: The likelihood of extubation success is predicted by the nomogram constructed by the present application.

[0068] As a preference, as Figure 4As shown, the nomogram contains 7 parameters, including the type of surgery, the first measured ALB (albumin) after surgery, the OI (oxygenation index) 5 minutes after extubation, the first measured AST (glutamic-oxaloacetic transaminase) after surgery, the back LUS score, the overall LUS score, and the intubation history.

[0069] As a preferred, the OI calculation formula is PaO2 / FiO2;

[0070] As a preferred, the extubation failure criteria is SpO2 < 90% or the need for nasal high flow oxygen or the need for re-intubation.

[0071] Wherein PaO2 is the arterial oxygen partial pressure, and FiO2 is the percentage of inhaled oxygen concentration.

[0072] When the normal value is 400-500 mmHg, if PaO2 is significantly reduced, increasing the oxygen concentration in inhaled air will not help to further increase the PaO2 concentration, and an oxygenation index below 300 mmHg indicates pulmonary respiratory dysfunction. Arterial blood gas was taken before incision and 5 minutes after extubation. PaO2, FiO2, RR, and expiratory tidal volume were analyzed simultaneously. Oxygenation index was calculated.

[0073] Embodiment:

[0074] This embodiment includes all surgical patients from December 2022 to August 2023 by the method shown in Figure 5 Among the 227 patients who met the conditions during the study period, 130 patients were enrolled, of which 17 patients developed postoperative pulmonary complications (PPCs) within 7 days after surgery, with an incidence of 13.1%. Patients who received high-flow oxygen support therapy after extubation had a significantly higher probability of developing PPCs within 7 days than patients who did not receive high-flow oxygen support therapy. The baseline data of the patients are shown in Table 2.

[0075] Table 2 Comparison of clinical data between groups of all patients

[0076]

[0077] The above is only a preferred embodiment of the present application and is not intended to limit the present application. For those skilled in the art, the present application can have various modifications and changes. Any modification, equivalent replacement, improvement, etc. within the spirit and principles of the present application shall be included in the protection scope of the present application.

Claims

1. A clinical prediction method for accurate extubation in PACU for elderly patients undergoing general anesthesia and long-term mechanical ventilation, characterized by: Including steps: S1: Elderly patients were included according to pre-specified inclusion and exclusion criteria; S2: Informed consent was provided to elderly patients who met the inclusion criteria; S3: Perform anesthesia resuscitation on elderly patients admitted to the PACU who are undergoing general anesthesia, and then conduct pre-weaning assessment and predefined weaning preparation according to the SBT to determine whether the patient is able to perform a spontaneous breathing trial; S4: bedside lung ultrasound followed by SBT test, after which the endotracheal tube is removed. S5: The possibility of extubation is predicted using the nomogram constructed by the present invention.

2. The clinical prediction method for accurate extubation in PACU for elderly patients undergoing general anesthesia and long-term mechanical ventilation according to claim 1, characterized in that: In step S1, The inclusion criteria for patients were: age ≥65 years, general anesthesia for surgery, and mechanical ventilation for more than 3 hours; Exclusion criteria for patients were: tracheotomy, inability to undergo lung or diaphragm ultrasound examination, central respiratory failure, myasthenia gravis, loss of diaphragmatic spontaneous activity, and comorbid end-stage cardiopulmonary disease.

3. The clinical prediction method for accurate extubation in PACU for elderly patients undergoing general anesthesia and long-term mechanical ventilation according to claim 1, characterized in that: In step S2, the chest wall is divided into 12 regions, and the lung ultrasound score of each region is as follows: 0 points, normal lung ventilation: mainly A lines, that is, normal lungs; 1 point, moderate reduction of lung ventilation: multiple isolated B lines or fused B lines less than 50% of the scanned intercostal space during vertical scanning; 2 points, severe decrease in lung ventilation: diffuse fusion B lines, or very small consolidation below the pleura; 3 points, complete disappearance of pulmonary ventilation: hepatoid changes in lung tissue with or without air bronchograms; The LUS score of each area was calculated based on the ultrasound images of the front, outside, and back of the patient's lungs, and the scores of the 12 areas and the total LUS score were recorded separately.

4. The clinical prediction method for accurate extubation in PACU of elderly patients under general anesthesia and long-term mechanical ventilation according to claim 1, characterized in that: In step S3 , the predefined weaning preparation is: SpO 2 ≥ 90% with FiO 2 ≤ 0.4, positive end-expiratory pressure ≤ 8 cmH 2 O, and low / no dose of vasopressors.

5. The clinical prediction method for accurate extubation in PACU for elderly patients undergoing general anesthesia and long-term mechanical ventilation according to claim 1, characterized in that: In step S4, after extubation, oxygen is administered through a nasal cannula; the gas flow is adjusted to maintain SpO2 greater than or equal to 92%, and if any signs of respiratory distress occur, noninvasive respiratory support and assisted ventilation or re-intubation are used under the supervision of the attending physician.

6. The clinical prediction method for accurate extubation in PACU for elderly patients undergoing general anesthesia and long-term mechanical ventilation according to claim 5, characterized in that: Assisted ventilation or reintubation is performed when any of the following conditions are met: (1) RR>35 bpm for more than 5 minutes; (2) SpO2 < 90%; (3) HR>140 bpm or HR sustained change>20%; (4) FiO2 ≥ 50% when PaO2 < 80 mmHg; (5) PaCO2>45 mmHg or change in PaCO2 after extubation ≥20%, pH<7.33; (6) Symptoms include respiratory muscle fatigue or increased difficulty breathing.

7. The clinical prediction method for accurate extubation in PACU for elderly patients undergoing general anesthesia and long-term mechanical ventilation according to claim 1, characterized in that: In step S5 , the nomogram includes the type of surgery, first ALB after surgery, OI 5 minutes after extubation, first AST after surgery, back LUS score, overall LUS score, and intubation history.

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